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Advance Care Planning

Advance Care Planning (ACP) is a process of communication that helps patients make decisions for their own future healthcare options. In an ACP discussion, patients are guided to understand, reflect upon, and discuss their goals, values and beliefs; then led to state their preferences with regards to future healthcare treatments. ACP also includes nominating a “nominated healthcare spokesperson” who can make decisions on the patient’s behalf. The documented discussion provides guidance for the medical team in making decisions when crisis strike and the patient is no longer able to communicate.

More information on Advance Care Planning in Singapore can be found from the following websites:

With funding administered from the Agency of Integrated Care, KTPH began its Advance Care Planning initiative in 2013. This pilot programme is part of a nation-wide implementation championed by Agency for Integrated Care. Our local Advance Care Planning (ACP) approach is adopted from the Respecting Choices framework which originated from the United States. In KTPH, ACP is being rolled out through pilots in various departments. The pilot started from the palliative care service in Jan 2013. It has since extended to areas such as geriatrics, transitional care, dementia, renal and diabetes centre.

If you would like to find out more about Advance Care Planning, please email to or call KTPH Mainline 6555 8000.

Stages of Advance Care Planning Over the Life Time of Adults
 General ACP Discussion  Disease Specific-ACP  Preferred Plan of Care-ACP

Inclusion Criteria

  • Adult, generally healthy or with early chronic disease
  • Has decision-making capacity


  • Appoint substitute decision maker(s)
  • Decision on goal of care if one is to be rendered severely mentally impaired with low chance of recovery
  • Comfort care
  • Life-sustaining


Inclusion Criteria

  • Adult, with decision-making capacity
  • Organ failure with recurrent hospital admissions and declining function


  • Appoint substitute decision maker(s)
  • Statement of treatment preference in 3 clinical scenarios:
    1. Serious complications with low chance of survival
    2. Serious complications with low chance of recovery of physical function or ability to communicate and will require total nursing care
    3. Serious complications with high chance of mental incapacity and will require total nursing care
  • Specific disease-related care

Inclusion Criteria

  • Adult, 'no surprise population', with decision-making capacity (DMC)
  • Include family members / other informants who have demonstrated acts of care for patients lacking in DMC


  • Care options on CPR
  • Care goals on medical intervention when one suffer a potentially life threatening crisis
  • Preference on place of care
  • Preference on place of death
  • Appointment of substitute decision maker(s)

Healthy adults

Adults with progressive, life-limiting illness, suffering frequent complications

Adults whom it would not be a surprise if they died in the next 12 months

ACP Clinic is open from Monday - Friday in Clinic C41.
ACP Clinic sessions are facilitated by our trained facilitators.

For enquiries, please contact KTPH Mainline at 6555 8000.

Dying at home is what many want, but few do — The Straits Times, 9 July 2017
My grandpa wanted to pass on at home and I saw how meaningful such home care was for my grandpa. Professional support from nurses at home is key, but rising manpower costs make it prohibitive for many lower- or middle-income families to afford it in order to honour their wishes of returning home.

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'Die-logue', education needed on dying well — The Straits Times, 30 May 2017
There is a huge gap to cross before we become a death-friendly and a death-literate society.

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The day I wanted my father to die — The Straits Times Online, 15 August 2014
It is abhorrent to contemplate the death of one's parents, yet we have to do that, at some point. Talking about
end-of-life issues is an essential part of preparing for that eventuality.
It is abhorrent to contemplate the death of one's parents, yet we have to do that, at some point. Talking about end-of-life issues is an essential part of preparing for that eventuality.

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Booster shot for palliative care — The Straits Times, Mind Your Body, 17 July 2014
As Singapore's population ages, more nurses are being trained in end-of-life care.

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Honouring his last wishes — The Straits Times, Mind Your Body, 10 July 2014
When you are lying on a bed in the intensive care unit of a hospital, so sick that you are no longer able to interact with anyone, what would you choose?

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Many prefer to die at home, but few do: Poll — The Straits Times, 9 April 2014
Most Singaporeans want to die at home and not in hospital, yet not many of them eventually do.

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To go gently - or not - into that good night — The Straits Times, 18 January 2014
What Britain and other countries know, and the United States is learning, is that every cancer need not be Verdun, a war of attrition waged regardless of the cost or the casualties.

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Advance Planning eases end-stage suffering — The Straits Times, 2 January 2014

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